2.
<ul><li>The first written reference to the use of tobacco </li></ul><ul><li>dates back to the discovery of the Americas, in </li></ul><ul><li>the work of Fray Bartolomé de las Casas, </li></ul><ul><li>(&quot;History of the Indies“), where two Spanish </li></ul><ul><li>settlers saw Indians smoking. </li></ul><ul><li>Nicotiana , the generic name of the </li></ul><ul><li>tobacco plant, originates from </li></ul><ul><li>Dr. Jean Nicot (1560). </li></ul>SMOKING A HISTORY FROM PERMISSIVENESS TO RESTRICTION

3.
16th century <ul><li>Tobacco was believed to be the &quot;panacea grass“, with healing powers against all ailments (even asthma). </li></ul><ul><li>On the other hand, there were always critics of smoking ( James I of England), with criteria similar to those found today . </li></ul><ul><li>Tobacco consumption spread to many European and Asian countries. </li></ul><ul><li>Havana was the great tobacco center. </li></ul>James I of England

4.
1 7th century <ul><li>Tobacco sales at the end of the 16th century were a great business, and tobacco plantations became universal - even exceeding potato crops. </li></ul><ul><li>The consumption of tobacco became popular, and nicotine was even prescribed for therapeutic purposes. </li></ul><ul><li>In catholic churches and in the Basilica of the Vatican, tobacco consumption was prohibited. </li></ul>

5.
18th century <ul><li>The nobility of the rococo used to inhale the smoke through the nose. </li></ul><ul><li>For the first time, in 1761, John Hill </li></ul><ul><li>associated tobacco with cancer, thanks </li></ul><ul><li>to the diagnosis of cancerous polyps in </li></ul><ul><li>heavy snuff consumers. </li></ul>

6.
19th century <ul><li>In 1880, James Bonsack invented a </li></ul><ul><li>machine for rolling cigarettes. </li></ul><ul><li>This expanded the tobacco </li></ul><ul><li>industry, with advertising </li></ul><ul><li>claiming smoking to be </li></ul><ul><li>beneficial for health. </li></ul><ul><li> </li></ul>Bonsack's cigarette rolling machine, as shown on U.S. patent 238,640.

7.
20th century <ul><li>In 1935, Fritz Lickint published a </li></ul><ul><li>number of studies relating cancer </li></ul><ul><li>to cigarette smoking. </li></ul><ul><li>Hoffman in the 1950s established that </li></ul><ul><li>smoking increases the risk of </li></ul><ul><li>suffering cancer of the mouth, neck, </li></ul><ul><li>esophagus, larynx and lungs. </li></ul>

8.
<ul><li>Finally, Richard Doll and Bradford Hill, in a </li></ul><ul><li>rigorous epidemiological study, </li></ul><ul><li>demonstrated the reality of the relationship </li></ul><ul><li>between cancer and tobacco. </li></ul><ul><li>1970s: Great social concern about the consequences of smoking. </li></ul><ul><li>1980s: First evidence that lung cancer increases in women married to smoking men. </li></ul>20th century

9.
<ul><li>The tobacco industry in its zeal to continue with the business, and in collaboration with national institutes of cancer, designed new formulations (filters, low nicotine cigarettes) to suggest that smoking thus might be less harmful. </li></ul>21st century

10.
PREVENTIVE LEGISLATION <ul><li>Warsaw Declaration (2002): Politicians and WHO see the need for a &quot;Smoke-Free World&quot;. </li></ul><ul><li>Marco Convention: Approved by 192 countries of the WHO, during the World Health Assembly (Geneva on May 21, 2003) </li></ul><ul><ul><ul><li>First international public health treaty: It attempts to regulate a product that kills its consumers. The aim is to reach children and young people. </li></ul></ul></ul><ul><li>Aftercare sanitary measures, regulating the sale, supply, consumption and advertising of tobacco. </li></ul>“ It tries to banish the social acceptance of smoking to improve the quality of life of individuals”

11.
EVOLUTION OF THE CONCEPT OF SMOKING <ul><li>1960s </li></ul><ul><li>Status of the &quot;modern&quot; individual. </li></ul><ul><li>1970s </li></ul><ul><li>Consumption as a &quot;dependency&quot;. </li></ul><ul><li>1980s </li></ul><ul><li>Consumption as an &quot;addiction&quot;. </li></ul><ul><li>1990s </li></ul><ul><li>“ The clinic of smoking”. </li></ul><ul><li>XXI Century </li></ul><ul><li>Smoking is considered “nicotine </li></ul><ul><li>drug addiction”. </li></ul>

12.
Is smoking comparable to the effects of other substances such as alcohol, barbiturates, heroin and cocaine?

13.
To answer this question we must differentiate between... <ul><li>Habituation </li></ul><ul><li>“ Repeated consumption of a particular drug”, which is characterized by: </li></ul><ul><li>No compulsive desire to continue consuming. </li></ul><ul><li>Moderate tendency to increase the dose. </li></ul><ul><li>Some degree of physical dependence but without withdrawal symptoms. </li></ul><ul><li>Effects that are detrimental to the individual. </li></ul><ul><li>Addiction </li></ul><ul><li>On the other hand is characterized by: </li></ul><ul><li>Compulsive desire to consume. </li></ul><ul><li>Getting drugs desperately. </li></ul><ul><li>Physical and psychological dependence caused by drugs. </li></ul><ul><li>Detrimental effects for the individual and society. </li></ul>

14.
CLASSIFICATION OF SMOKING <ul><li>First it was seen as a habit. </li></ul><ul><li>In 1988 the National Center of Health defined </li></ul><ul><li>the psychoactive effects of nicotine. </li></ul><ul><li>Nicotine: Addictive substance that induces </li></ul><ul><li>pharmacological and behavioral processes </li></ul><ul><li>similar to those of drugs such as heroin and cocaine. </li></ul><ul><li>In 1992 the WHO, in its International </li></ul><ul><li>Classification of Diseases, suggested nicotine </li></ul><ul><li>dependence. </li></ul>

15.
DEPENDENCE <ul><li>Dependence is characterized by at least 3 of the </li></ul><ul><li>following symptoms for 12 months: </li></ul><ul><li>1. The need for increasing amounts of cigarettes </li></ul><ul><li>(tolerance). </li></ul><ul><li>2. The effect decreases with continued consumption </li></ul><ul><li>(tolerance). </li></ul><ul><li>3. Withdrawal symptoms. </li></ul><ul><li>4. Smoking is resorted to in order to lessen the syndrome. </li></ul>

16.
Physical and psychological dependence <ul><li>Physical dependence </li></ul><ul><li>7 seconds pass from inhalation of nicotine until its effects are demonstrated in the brain: </li></ul><ul><li>Pleasure sensation. </li></ul><ul><li>Supposed increase in mental </li></ul><ul><li>concentration. </li></ul><ul><li>Mental stability. </li></ul><ul><li>Decreased anxiety. </li></ul><ul><li>“ Physical dependence is produced by constant exposure of the neurons to nicotine&quot; </li></ul>

17.
<ul><li>It is produced when the smoker associates environmental stimulus with the act of smoking. </li></ul><ul><li>Environmental factors: waiting </li></ul><ul><li>room, bar, restaurant, car… </li></ul><ul><li>Emotional factors: stress, </li></ul><ul><li>anxiety, boredom, loneliness... </li></ul><ul><li>Social events: festivals, </li></ul><ul><li>meetings, holidays… </li></ul><ul><li>This dependence is very related </li></ul><ul><li>to the concept of automatism: </li></ul><ul><li>“ repetitive behavior of the </li></ul><ul><li>smoker”. </li></ul><ul><li>“ When the act of smoking, the managing of the cigarette, the smell, flavor … becomes agreeable, this is when we talk of psychological dependence&quot; </li></ul>PSYCHOLOGICAL DEPENDENCE

18.
“ To overcome the desire to smoke is the most difficult thing for the smoker &quot; <ul><li>During dreaming, </li></ul><ul><li>resensitization is produced </li></ul><ul><li>to the effects of the nicotine: </li></ul><ul><li>“ many smokers agree </li></ul><ul><li>that the best cigarettes are </li></ul><ul><li>the first ones of the </li></ul><ul><li>morning”. </li></ul><ul><li>Physiologically, through the </li></ul><ul><li>cholinergic receptors, </li></ul><ul><li>nicotine is responsible for </li></ul><ul><li>the dependence, tolerance, </li></ul><ul><li>and w ithdrawal symptoms . </li></ul>

19.
Reasons for tolerance <ul><li>1. Metabolic reasons : Tobacco induces the expression of certain liver enzymes that increase tolerance to certain hydrocarbons in the combustion of some tars. </li></ul><ul><li>2. Pharmacological reasons : These explain desensitization of the cholinergic receptors by increasing concentrations of the agonist. </li></ul><ul><li>3. Psychological reasons : These explain the adaptive and compensatory responses that would reduce the impact of the nicotine dose. </li></ul>

20.
This is characterized by migraine, motion sicknesses, insomnia, irritability, anxiety, an increase in appetite, an increase in weight, loss of mental concentration, loss of memory. <ul><li>The behavioral effects of nicotine are associated to the neuroregulatory actions of this substance upon other neurotransmitters (dopamine, norepinephrine, β-endorphin and acetylcholine). </li></ul>“ Withdrawal symptom”

21.
<ul><li>This is based on genes of a Mendelian pattern and others characterized by polygenic inheritance. </li></ul><ul><li>Racial or ethnic factors. </li></ul><ul><li>Studies with twins in search of environmental factors that influence the same genetic base. </li></ul>GENETIC BASES OF TOBACCO DEPENDENCE Two aspects are studied : 1. Influence of genotype upon acquisition of the habit during infancy or youth. 2. Influence of genotype upon the maintenance of consumption during adult life.

22.
Effects of nicotine on the CNS <ul><li>Its pleasant effects are related to stimulation of the </li></ul><ul><li>dopaminergic or catecholaminergic pathways; the most </li></ul><ul><li>implicated route is the mesolimbic pathway (extending from the </li></ul><ul><li>ventral tegmental zone to the nucleus accumbens and frontal cortex) </li></ul><ul><li>Projections reaching this nucleus, the amygdala and the </li></ul><ul><li>hippocampus, are associated with the effect of nicotine on memory, </li></ul><ul><li>as well as to the mental changes associated with the withdrawal </li></ul><ul><li>syndrome . </li></ul><ul><li>The projections that extend to the cortex in the perfrontal, </li></ul><ul><li>orbitofrontal and anterior cingular regions are associated with the </li></ul><ul><li>experiences generated by consumption of the drug and the need to </li></ul><ul><li>continue consuming. </li></ul>Next View

24.
<ul><ul><ul><li>&quot; Therefore genes that </li></ul></ul></ul><ul><ul><ul><li>regulate the flow of dopamine, </li></ul></ul></ul><ul><ul><ul><li>whose levels are increased </li></ul></ul></ul><ul><ul><ul><li>with nicotine, stimulating basal </li></ul></ul></ul><ul><ul><ul><li>ganglia such as the nucleus </li></ul></ul></ul><ul><ul><ul><li>accumbens, like other drugs </li></ul></ul></ul><ul><ul><ul><li>(such as cocaine or morphine) </li></ul></ul></ul><ul><ul><ul><li>are good candidates for induction </li></ul></ul></ul><ul><ul><ul><li>to the habit “ </li></ul></ul></ul>Genes...! Salvador Dalí, 1957

25.
Cloning of the genes that encode for 5 dopamine receptors (DRD1 to DRD5) <ul><li>One of the alleles of DRD1 is more frequent in smokers that in non- </li></ul><ul><li>smokers. </li></ul><ul><li>A polymorphism in the 3' region of the DRD2 gene is associated with </li></ul><ul><li>lesser availability of dopamine receptors in the striate nucleus. </li></ul><ul><li>Relationship of the DAT protein. A polymorphism of the SLC6A3 gene </li></ul><ul><li>is associated with high values of dopamine, with a lesser </li></ul><ul><li>predisposition to develop the habit, greater ease in abandoning it, </li></ul><ul><li>and prolonged periods of abstinence. </li></ul>

26.
Other routes of study to understand the genetic bases of this habit are the following systems: <ul><li>-Serotonin </li></ul><ul><li>-Cholinergic </li></ul><ul><li>-Opioid </li></ul><ul><li> -Aminoacidergic </li></ul><ul><li>-Cannabinoid </li></ul><ul><li>- Routes related to the levels of nitric acid </li></ul>

27.
THE SANITARY PROBLEM IN NUMBERS: FROM THE HEALING PROPERTIES OF TOBACCO TO PHYSIOPATHOLOGY <ul><li>Nowadays many scientific and epidemiological studies confirm that &quot;panacea grass&quot; is a &quot;poison&quot;. </li></ul><ul><li>Nonetheless, the denomination of &quot;poison&quot; has been rejected by smokers, tobacco companies and public authorities. </li></ul>

29.
<ul><li>The first avoidable cause of death in the world, despite the fact that 33% of all smokers are aware of the close relationship between smoking and cancer. </li></ul><ul><li>40% of smokers do not think that abandoning the habit is the best thing for cancer prevention. </li></ul><ul><li>43% of smokers continue smoking despite having respiratory and/or carcinogenic disorders. </li></ul>1 st cause of avoidable death in the world Some data...

30.
More data... 1 st cause of avoidable death in the world Number of tobacco smoker deaths/year Deaths due to AIDS + Deaths due to malaria + Deaths from childhood diseases avoidable with Vaccines 5 million deaths =

31.
<ul><li>20 to 40 fold greater risk in smokers of suffering lung cancer. </li></ul><ul><li>Life expectancy of a consumer of 20 cigarettes a day for 25 years is 25% less than for a non-smoker. </li></ul><ul><li>Survival after the diagnosis of lung cancer: 13 months. </li></ul><ul><li>If the tumor is removed: 50% patient life expectancy at 5 years. </li></ul><ul><li>60% non-smokers exposed to environmental tobacco smoke. </li></ul><ul><li>Smoking is the cause of approximately 30 human diseases (cardio- and cerebrovascular diseases, chronic obstructive pulmonary disease, and cancer). </li></ul>1 st cause of avoidable death in the world More and more data...

35.
<ul><li>The possibility that smokers do not suffer lung cancer is very </li></ul><ul><li>small, and is due to very scant genetic protection </li></ul>View 87% of deaths from lung cancer 82% of deaths from lung diseases Caused by smoking Smoking people 98% of all cases of lung cancer

37.
SYMPTOMS OF LUNG CANCER <ul><li>Persistent cough that worsens over time </li></ul><ul><li>Pain in the chest </li></ul><ul><li>Phlegm with blood </li></ul><ul><li>Wheezing in the chest and shortness of breath </li></ul><ul><li>Susceptibility to pneumonia and bronchitis </li></ul><ul><li>Swelling of the face </li></ul><ul><li>Loss of weight </li></ul><ul><li>Related other factors </li></ul>

47.
PREVENTION, CLINICAL ETHICS AND RESPONSIBILITY, AND SOCIAL CONSCIENCE <ul><li>WHO: “Major avoidable reason of morbidity-mortality in developed </li></ul><ul><li>countries” </li></ul><ul><li>Entails high social and sanitary cost </li></ul><ul><li>AIM : Prevention and control of smoking </li></ul><ul><li>Therapy of addiction and consequences in the smoker </li></ul><ul><li>Social conscience </li></ul>Avoid smoking

49.
SOCIAL CONSCIENCE (I) Necessities <ul><li>Smoke-free spaces. </li></ul><ul><li>Elimination of tobacco advertisements and brand sponsorship. </li></ul><ul><li>Establishment of fiscal politics for tobacco. </li></ul>The idea is not to suppress or censure smokers; the aim is to ensure freedom to health among non-smokers: CIVIC CONSCIENCE

50.
Who has to establish tobacco's rules? SOCIAL CONSCIENCE (II) To preserve public health THE GOVERMENT AND CIVIL SERVICES To preserve sanitary and medical health PHYSICIANS AND SMOKING TREATMENT AND PREVENTION EXPERTS (CLINICAL ETHICS)

51.
CLINICAL ETHICS Difference between apparent freedom of action and truly voluntary decisions The cigarette is lighted by the smoker Apparent voluntary action However, it's not a truly free action but rather a lack of will to refrain from smoking Is the intervention of physicians legitimate? The physician has to advise the cessation of smoking (proposition, not imposition) The main function of the physician here is to educate and instruct rather than to cure. (One of every two smokers dies prematurely)

52.
In brief … It's a worldwide public health problem that requires: INTERNATIONAL COOPERATION and SOCIAL CONSCIENCE Smoking habit Sanitary Social Economic Environmental … consequences